Feasibility of extended ambulatory electrocardiogram monitoring to identify silent atrial fibrillation in high-risk patients: the Screening Study for Undiagnosed Atrial Fibrillation (STUDY-AF)

Mintu P Turakhia, Aditya J Ullal, Donald D Hoang, Claire T Than, Jared D Miller, Karen J Friday, Marco V Perez, James V Freeman, Paul J Wang, Paul A Heidenreich, Mintu P Turakhia, Aditya J Ullal, Donald D Hoang, Claire T Than, Jared D Miller, Karen J Friday, Marco V Perez, James V Freeman, Paul J Wang, Paul A Heidenreich

Abstract

Background: Identification of silent atrial fibrillation (AF) could prevent stroke and other sequelae.

Hypothesis: Screening for AF using continuous ambulatory electrocardiographic (ECG) monitoring can detect silent AF in asymptomatic in patients with known risk factors.

Methods: We performed a single-center prospective screening study using a wearable patch-based device that provides up to 2 weeks of continuous ambulatory ECG monitoring (iRhythm Technologies, Inc.). Inclusion criteria were age ≥55 years and ≥2 of the following risk factors: coronary disease, heart failure, hypertension, diabetes, sleep apnea. We excluded patients with prior AF, stroke, transient ischemic attack, implantable pacemaker or defibrillator, or with palpitations or syncope in the prior year.

Results: Out of 75 subjects (all male, age 69 ± 8.0 years; ejection fraction 57% ± 8.7%), AF was detected in 4 subjects (5.3%; AF burden 28% ± 48%). Atrial tachycardia (AT) was present in 67% (≥4 beats), 44% (≥8 beats), and 6.7% (≥60 seconds) of subjects. The combined diagnostic yield of sustained AT/AF was 11%. In subjects without sustained AT/AF, 11 (16%) had ≥30 supraventricular ectopic complexes per hour.

Conclusions: Outpatient extended ECG screening for asymptomatic AF is feasible, with AF identified in 1 in 20 subjects and sustained AT/AF identified in 1 in 9 subjects, respectively. We also found a high prevalence of asymptomatic AT and frequent supraventricular ectopic complexes, which may be relevant to development of AF or stroke. If confirmed in a larger study, primary screening for AF could have a significant impact on public health.

© 2015 Wiley Periodicals, Inc.

Figures

Figure 1
Figure 1
Zio patch symptom trigger button and device placement. Subjects were instructed to press the symptomatic event trigger (A) if symptoms such as dizziness, chest pain, shortness of breath, or heart palpitations developed during monitoring. Device placement (B) for the wearable adhesive patch–based device is over the patient's left pectoral region. (Images courtesy of iRhythm Technologies Inc., San Francisco, CA.)
Figure 2
Figure 2
The study flow chart shows detailed inclusion and exclusion criteria for study participation and completion. Abbreviations: AF, atrial fibrillation; SVT, supraventricular tachycardia; TIA, transient ischemic attack.
Figure 3
Figure 3
Sample rhythm strips exhibiting episodes of (A) AF, (B) sustained SVT that was determined to be AT, and (C) NSVT detected in separate study participants. Abbreviations: AF, atrial fibrillation; AT, atrial tachycardia; NSVT, nonsustained ventricular tachycardia; SVT, supraventricular tachycardia.

References

    1. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham Study. Arch Intern Med. 1987;147:1561–1564.
    1. Lin HJ, Wolf PA, Benjamin EJ, et al. Newly diagnosed atrial fibrillation and acute stroke. The Framingham Study. Stroke. 1995;26:1527–1530.
    1. Flaker GC, Belew K, Beckman K, et al. Asymptomatic atrial fibrillation: demographic features and prognostic information from the Atrial Fibrillation Follow‐up Investigation of Rhythm Management (AFFIRM) study. Am Heart J. 2005;149:657–663.
    1. Cullinane M, Wainwright R, Brown A, et al. Asymptomatic embolization in subjects with atrial fibrillation not taking anticoagulants: a prospective study. Stroke. 1998;29:1810–1815.
    1. Marfella R, Sasso FC, Siniscalchi M, et al. Brief episodes of silent atrial fibrillation predict clinical vascular brain disease in type 2 diabetic patients. J Am Coll Cardiol. 2013;62:525–530.
    1. Camm AJ, Lip GY, De Caterina R, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association [published corrections appear in Eur Heart J. 2013;34:790 and Eur Heart J. 2013;34:2850–2851]. Eur Heart J. 2012;33:2719–2747.
    1. Goldstein LB, Bushnell CD, Adams RJ, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association [published correction appears in Stroke. 2011;42:e26]. Stroke. 2011;42:517–584.
    1. Welles CC, Whooley MA, Na B, et al. The CHADS2 score predicts ischemic stroke in the absence of atrial fibrillation among subjects with coronary heart disease: data from the Heart and Soul Study. Am Heart J. 2011;162:555–561.
    1. Benjamin EJ, Levy D, Vaziri SM, et al. Independent risk factors for atrial fibrillation in a population‐based cohort. The Framingham Heart Study. JAMA. 1994;271:840–844.
    1. Turakhia MP, Hoang DD, Zimetbaum P, et al. Diagnostic utility of a novel leadless arrhythmia monitoring device. Am J Cardiol. 2013;112:520–524.
    1. Rosenberg MA, Samuel M, Thosani A, et al. Use of a noninvasive continuous monitoring device in the management of atrial fibrillation: a pilot study. Pacing Clin Electrophysiol. 2013;36:328–333.
    1. Binici Z, Intzilakis T, Nielsen OW, et al. Excessive supraventricular ectopic activity and increased risk of atrial fibrillation and stroke. Circulation. 2010;121:1904–1911.
    1. Dewland TA, Vittinghoff E, Mandyam MC, et al. Atrial ectopy as a predictor of incident atrial fibrillation: a cohort study. Ann Intern Med. 2013;159:721–728.
    1. Guyatt GH, Akl EA, Crowther M, et al; American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence‐Based Clinical Practice Guidelines [published corrections appear in Chest. 2012;141:1129 and Chest. 2012;142:1698]. Chest. 2012;141(2 suppl):7S–47S.
    1. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2014;130:2071–2104.
    1. Doliwa PS, Frykman V, Rosenqvist M. Short‐term ECG for out of hospital detection of silent atrial fibrillation episodes. Scand Cardiovasc J. 2009;43:163–168.
    1. Engdahl J, Andersson L, Mirskaya M, et al. Stepwise screening of atrial fibrillation in a 75‐year‐old population: implications for stroke prevention. Circulation. 2013;127:930–937.
    1. Gaillard N, Deltour S, Vilotijevic B, et al. Detection of paroxysmal atrial fibrillation with transtelephonic EKG in TIA or stroke patients. Neurology. 2010;74:1666–1670.
    1. Jabaudon D, Sztajzel J, Sievert K, et al. Usefulness of ambulatory 7‐day ECG monitoring for the detection of atrial fibrillation and flutter after acute stroke and transient ischemic attack. Stroke. 2004;35:1647–1651.
    1. Sanmartín M, Fraguela Fraga F, Martín‐Santos A, et al. A campaign for information and diagnosis of atrial fibrillation: “Pulse Week” [article in English, Spanish]. Rev Esp Cardiol (Engl Ed). 2013;66:34–38.
    1. Tayal AH, Tian M, Kelly KM, et al. Atrial fibrillation detected by mobile cardiac outpatient telemetry in cryptogenic TIA or stroke. Neurology. 2008;71:1696–1701.
    1. Wheeldon NM, Tayler DI, Anagnostou E, et al. Screening for atrial fibrillation in primary care. Heart. 1998;79:50–55.
    1. Seet RC, Friedman PA, Rabinstein AA. Prolonged rhythm monitoring for the detection of occult paroxysmal atrial fibrillation in ischemic stroke of unknown cause. Circulation. 2011;124:477–486.
    1. Lowres N, Neubeck L, Redfern J, et al. Screening to identify unknown atrial fibrillation: a systematic review. Thromb Haemost. 2013;110:213–222.
    1. Hart RG, Pearce LA, Aguilar MI. Meta‐analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146:857–867.
    1. Shah SV, Gage BF. Cost‐effectiveness of dabigatran for stroke prophylaxis in atrial fibrillation. Circulation. 2011;123:2562–2570.
    1. Canestaro WJ, Patrick AR, Avorn J, et al. Cost‐effectiveness of oral anticoagulants for treatment of atrial fibrillation. Circ Cardiovasc Qual Outcomes. 2013;6:724–731.
    1. Savelieva I, Camm AJ. Practical considerations for using novel oral anticoagulants in patients with atrial fibrillation. Clin Cardiol. 2014;37:32–47.
    1. Friberg L, Engdahl J, Frykman V, et al. Population screening of 75‐ and 76‐year‐old men and women for silent atrial fibrillation (STROKESTOP). Europace. 2013;15:135–140.
    1. Reiffel J, Verma A, Halperin JL, et al. Rationale and design of REVEAL AF: a prospective study of previously undiagnosed atrial fibrillation as documented by an insertable cardiac monitor in high‐risk patients. Am Heart J. 2014;167:22–27.
    1. Healey JS, Connolly SJ, Gold MR, et al; ASSERT Investigators . Subclinical atrial fibrillation and the risk of stroke. N Engl J Med. 2012;366:120–129.
    1. Glotzer TV, Daoud EG, Wyse DG, et al. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study. Circ Arrhythm Electrophysiol. 2009;2:474–480.
    1. Ziegler PD, Glotzer TV, Daoud EG, et al. Incidence of newly detected atrial arrhythmias via implantable devices in patients with a history of thromboembolic events. Stroke. 2010;41:256–260.
    1. Ip J, Waldo AL, Lip GY, et al; IMPACT Investigators . Multicenter randomized study of anticoagulation guided by remote rhythm monitoring in patients with implantable cardioverter‐defibrillator and CRT‐D devices: rationale, design, and clinical characteristics of the initially enrolled cohort The IMPACT study. Am Heart J. 2009;158:364.e1–370.e1.

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